Neonatal transport practices and effectiveness of the use of low‐cost interventions on outcomes of transported neonates in Sub‐Saharan Africa: A systematic review and narrative synthesis

Abstract Background and Aims Neonatal deaths contribute significantly to under‐5 mortality worldwide with Sub‐Saharan Africa (SSA) alone accounting for 43% of global newborn deaths. Significant challenges in the region's health systems evidenced by huge disparities in health facility deliveries and poor planning for preterm births are major contributors to the high neonatal mortality. Many neonates in the region are delivered in suboptimal conditions and require transportation to facilities equipped for specialized care. This review describes neonatal transport across the subregion, focusing on low‐cost interventions employed. Methods We conducted a systematic review of studies on neonatal transport in SSA followed by a narrative synthesis. A search in the databases CINAHL, EMBASE, MEDLINE, Web of Science, African Index Medicus, and Google Scholar was performed from inception to March 2023. Two authors reviewed the full texts of relevant studies to determine eligibility for inclusion which was subsequently cross‐checked by a third reviewer using a random 30% overlay. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. Results A total of 20 studies were included in this review involving 11,895 neonates from 10 countries. All studies evaluated the transfer of neonates into referral centers from the peripheries. Most neonates were transferred by public transport (n = 12), mostly in the arms of caregivers with little communication between referring facilities. Studies reporting on ambulance transfers reported pervasive inadequacies in both human resources and transport equipment. No study reported on the use of Kangaroo mother care (KMC) in the transfer process. Conclusions The neonatal transport system across the SSA region is poorly planned, poorly resourced, and executed with little communication between facilities. Using cost‐effective measures like KMC and improved training of community health workers may be key to improving the outcomes of transported neonates.

Significant progress has been made in child survival since the institution of the Millennium Development Goals (MDGs), over 2 decades ago.However, despite increased facility delivery, which was a focus of the MDG, neonatal mortality in low and low-middleincome countries (LMIC) remains high.
Even though over 62 countries were able to achieve MDG 4, the target was missed globally with the under-5 mortality rate (U5MR) reducing by 53% over 25-year period (1990-2015) instead of the targeted 75%. 1 Globally, U5MR fell from 90.6 deaths per 1000 live births in 1990 to 42.5 per 1000 live births in 2015, 1 significantly below the MDG target.In percentage terms, the decline in neonatal mortality has been slower than that of postneonatal under-5 mortality: reducing by 47% compared with 58% globally.As a result, the portion of neonatal deaths among overall under-5 deaths increased from 40% in 1990 to 45% in 2015, 2 with several regions' resourcelimited settings exceeding a mortality rate of more than 50%. 3e Sustainable Development Goals (SDG), a follow-up from the MDGs has an aim for all countries to achieve a U5MR of 25 or fewer deaths per 1000 livebirths by 2030 (SDG target 3.2.1)and a neonatal mortality rate (NMR) of 12 or fewer deaths per 1000 livebirths by 2030. 4 About halfway into the SDG era, the global U5MR is estimated to have decreased by 59% to 37.7% deaths per 1000 live births in 2019 and NMR reduced by just over half from 36.6% in 1990 to 17.5% deaths per 1000 live births in 2019. 5This translates into a drop in the total number of deaths from 5.0 million in 1990 to 2.4 million in 2019. 5b-Saharan Africa (SSA) is currently made up of 48 out of the 52 countries on the African continent and is geographically located south of the Sahara Desert, 6 with an estimated total population of approximately 1.18 billion. 7It has differing statistics, economically and in health service delivery compared to other regions considered LMIC.Approximately, 40% of the world's population are extremely poor and live below the US $1.90-a-day poverty line.SSA accounts for 66% of the global extremely poor. 8A and Southern Asia alone accounted for 80% of the global neonatal deaths in 2019. 9Two-thirds of these occurred on the first day of life and almost three-quarters within the first week.The challenge to survive encountered by the neonate, therefore, starts at the place of delivery, with a risk of death up to 20 times higher in SSA and Southern Asia compared to high-income countries. 51][12] Unfortunately, in SSA, sick newborns in need of transfer to established specialized neonatal centers remain at risk of adverse outcomes because of under-resourced peripheral delivery facilities, lack of coordinated neonatal transport service, and frequently unsafe transfer practices.
Prompt attention to appropriate referral of sick newborns might therefore significantly contribute to a reduction in the high mortality occurring on the day of birth. 13allenges in every sector of the health system in SSA and most LMICs regarding newborn care including the absence of wellestablished ambulance services lend themselves to the need to explore the possibility of employing cost-effective but evidencebased, life-saving procedures in the neonatal transfer process.The results from such an exercise would inform technical guidelines for use by healthcare professionals, facilities, and organizations responsible for setting health system priorities and policies surrounding the transport of neonates in LMICs.The use of Kangaroo mother care (KMC) and other alternative methods of thermal stability for neonatal transport is not well studied in SSA, yet this has been one of the areas proposed for future research in several published studies on neonatal transport.
KMC is a practical, effective, and safe substitute for conventional neonatal care in preterm and low birthweight (LBW) infants mainly in resource-limited countries.It involves strapping the baby upright to the mother's chest in skin-to-skin contact.World Health Organization defines KMC with four components: early, continuous, and prolonged skin-to-skin contact between the newborn and mother, exclusive breastfeeding, early discharge from the health facility, and close follow-up at home. 14Previous studies have reported its benefits in reducing the risk of morbidity and mortality among LBW infants. 15e skin-to-skin component alone has also been reported to be associated with improved breastfeeding, cardiorespiratory stability, and improved responses to procedural pain in randomized controlled studies. 16,17.1 | Rationale While a review of neonatal transport in developing countries has been undertaken, 11 the field is advancing necessitating an updated review.The use of KMC for the care of stable newborns within neonatal units in resource-limited settings has been reported but there is a dearth of information on its use in neonatal transport.This study aimed to systematically review the literature on neonatal transport in SSA to explore all components including the use of costeffective procedures.

| METHODS
A systematic review was undertaken according to the prospectively developed review protocol which conformed to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. 18The review is registered with PROSPERO (registration number CRD42022352401).There were no restrictions placed on the date or language of the publication.However, the studies included were restricted to only those from SSA. Bibliographies of retrieved articles were reviewed for additional articles which meet the inclusion criteria.All selected articles were imported into RefWorks, ProQuest reference manager, and independently assessed by reviewers using the inclusion/ exclusion criteria.

| Inclusion criteria
All peer-reviewed publications on neonatal transport, describing transport modalities/processes and outcomes within SSA were assessed.

| Exclusion criteria
Case reports, protocols, editorials, commentaries, or studies on neonatal transport that were not published in SSA.For studies with uncertainty about meeting the inclusion criteria, or where relevant data could not be extracted from the study report, the authors were contacted via email for additional data or clarification.If this was not forthcoming the study was excluded.In the case of studies of mixed samples where only a proportion of the study population meets the inclusion criteria (e.g., only a proportion of the transported infants are neonates, or communication was partly about the maternal prelabour transfer), the study was included if relevant data could be extracted.

| Definitions
A neonate is defined as a newborn infant with a chronological age of 28 days or less without regard to the postmenstrual age at birth.
A caregiver is defined as the individual who accompanies the neonate during transport, as identified by the study, and could be a family member, such as a mother, father, aunt, grandmother, or friend.Facility type was categorized as either primary, secondary, or tertiary health centers as identified by each study.Primary health centers included public and private maternity units, health centers, and health facilities with in-patient care as defined by individual studies based on the country's health structure.

Pretransport
Healthcare providers include hospital/facility administrators, paramedics, and medically trained providers such as doctors, midwives, and nurses.

| Data extraction
Articles retrieved using the search strategy were initially screened by title and abstract against the inclusion criteria by E. O. and checked by H. S. and F. F. with any disagreement over potential article relevance resolved through discussion.
Eligible papers were read in full text independently by E. O. and F. F. for inclusion and E. O. extracted study characteristics and outcome data from the included studies using a predefined data extraction form (Excel spreadsheet) which was subsequently checked for accuracy by H. S. or F. F. Papers which met the inclusion criteria at the abstract stage, but where a full-text article could not be obtained even after contact with authors were included if enough data could be extracted from the abstract.Data extracted were summarized to include, authors, country of study, the study aims and objectives, research methods/design, participants, information on the transport/ transfer process, main findings, quality appraisal score, and study limitations.Summary characteristics were kept broad due to the vast methodological differences within and between the studies.For qualitative studies, directly reported participant data (e.g., verbatim quotations or scores), and author interpretations were extracted and analyzed separately in order not to distort the contextual basis required to understand barriers and enablers of an efficient neonatal transportation system for the region.

| Quality appraisal
All reviewers independently assessed the 20 full-text papers using the Mixed Methods Appraisal Tool (MMAT), Version 2018. 19Articles were assessed using the criteria within the tool that was appropriate for the study design; quantitative (randomized; nonrandomized: descriptive), qualitative, or mixed-methods design.Any disagreements were discussed within the team.No studies were excluded based on their quality but commented on in the narrative synthesis.

| Data summary and synthesis
The heterogeneity among the included studies, even for studies with similar methodologies made it taxing for combining quantitative data using meta-analysis, or a meta-synthesis for qualitative data.The general framework and specific tools outlined in the Economic and Social Research Council Guidance on the Conduct of Narrative Synthesis in Systematic Reviews 20 were applied.
We, therefore, proceeded to combine studies by summarizing their descriptive statistics followed by a textual narrative synthesis as opposed to a thematic synthesis.A textual synthesis held more potential to describe the gaps in the literature and to make transparent the heterogeneity between the studies as well as make the context and study characteristics of each study clearer.
To minimize the inherent selection bias of facility-based surveys regarding their population sample as well as minimizing bias in synthesizing studies, we have attempted to describe all outcomes and findings regardless of their statistical significance.

| RESULTS
Figure 1 gives a PRISMA flow diagram of the study search and selection process. 18Forty-seven publications were identified, and seven articles were identified through hand-searching the bibliographies of identified studies.Duplicates were removed leaving 47 papers that were screened against the inclusion/exclusion criteria by their titles and abstracts.A total of 22 studies were reviewed in full F I G U R E 1 Preferred Reporting Items for Systematic Reviews and Meta-analysis flowchart. 23ext.Out of these, two articles were excluded based on the exclusion criteria: The first is a registry-based study that focused on sociodemographic factors, pregnancy complications, and neonatal factors predicting admission to the neonatal unit without any distinction of outborn neonates 21 and the second study involved mother-baby pairs with data analysis mainly focussing on the mothers. 22A total of 20 articles met our inclusion criteria and were included in the final review and analysis.
The focus of the studies was varied.Three studies were community-based surveys, 27,32,42 two studies evaluated the quality/effectiveness of a dedicated neonatal ambulance service, 24,25 one study evaluated barriers to an effective neonatal transport service, 32 one study evaluated the cost-effectiveness of a dedicated ambulance service 33 and the rest (13) were facility-based surveys.
The majority (n = 18/20) of the studies were published after 2000 with only two studies published between 1989 and 1994.
Twelve of the studies was published after the last review of neonatal transport in developing countries. 11All studies evaluated the transfer of neonates into referral centers from the peripheries.
The study populations were homogeneous in terms of age, as the ages of all the study participants enrolled were less than 1 month.
The subgroup categories within studies however differed for example in gestational age, birthweight, and severity of illness as summarized in Table 1.
The included studies identified a total of 11,895 neonates who were either transferred into tertiary care from the peripheries or benefited from interhospital transport.Out of these, 848 neonates were included in two nonfacility-based studies which analyzed referrals by only community health workers into hospitals. 35][36][37][38][39][40][41]43

| Quality assessment
The quality of studies using the MMAT assessment is shown in (Appendix S2).All studies met the MMAT screening criteria questions.The two qualitative studies were of good quality with clearly defined research questions, sampling methods, and clear links between data collected and inferences.The quantitative studies were of varied quality.Most studies addressed the research question well but a few studies either had unclear aims 38 or the stated aim was not addressed in the final analysis. 36st quantitative studies described the target population well and used appropriate measurements.15/20 studies were judged to have a sample that was representative of the target population, in 5/ 20 studies it was not possible to tell if the sample was representative.
In sampling their participants, only one stated they used convenience sampling, however, a closer review of the studies suggested that most studies used convenience sampling.Most studies did not comment on any consideration about how study findings or the extent of missing data introduced biases.The discussion segments of some studies were limited and most studies often limited analyses to descriptive statistics on comparison groups and χ 2 or t tests to elucidate differences in outcomes.

| Synthesis of results
A neonatal transport service has several key components: Human resources, vehicles, and equipment, communication and family support, documentation and quality assurance, and feedback to referring units.Included studies varied greatly in their focus on the individual aspects of the transport service.These have been incorporated into four overarching themes including "mode of transport," "support during transport," "referral pathway and communication," and "neonatal care and access within health facilities."

| Mode of transport: Organized versus self-transport
As shown in Table 2, 16 studies either examined or commented on the mode of transport of neonates in the subregion.The mode of transport and neonatal outcomes were similar across studies regardless of study quality.Five studies examined regionalized/ organized ambulance transport services using ground transport, 4,24,43 private ground ambulances, 33 fixed-wing helicopters, and ground ambulances. 28Eight studies identified public transport as the main mode of transport with the majority (7/8) being transferred by taxis 12,34,35,37,38,40,41 and private vehicles. 30In one study, a comment is made about 10% of the transfers being made by ambulance but the other modes of transfer are not analyzed. 36Transfers on foot was the maximal mode of transport in three studies, 39,42 with one reporting as high as more than 30%. 40Reported average distances for many transfers were <80 km but up to 200 km in helicopter transfers 28 (Table 2).The reported time of travel was however considerable ranging from 15 min to 48 h. 35,38,43The reported average delay before admission to a referral center was 3.5 h with a maximum of 3 days. 37pport during transport: This is subdivided into (a) Use of equipment, KMC, or other low-cost interventions for transport and (b) human resources and family support: (a) Use of equipment, KMC, or other low-cost interventions for transport: In no study was KMC employed during transport.In five studies using ambulance transport, there was reported inadequate equipment during the transfer 24,30,32,41,43 and one study reported on an adapted ambulance with no equipment. 33e of these reported one neonate transferred with a hot water bottle to maintain thermal stability. 30In all other studies, transfers were made with babies in the caregivers' arms.No study examined any innovative models for transport or used illness severity scores (TRIPS, TOPS, SNAP-II, SNAPPE-II) in assessment, triage, and prediction of mortality 44,45 (Table 2).
(b) Human resources and family support: The five studies which examined a regionalized/organized transport service involved trained paramedics to accompany the transfer.In all the other remaining studies, transported neonates were accompanied by mothers or other family members.A health worker accompanied a proportion of the transfers in three studies -13% with nurses, 38 1.7% with a doctor and nurse, 12 and 7% with a nurse or other health professional 30 (Table 2).
Referral pathway and communication: All studies reported a lack of standard referral pathways with critical deficiencies in communication before, during, and after transport with the majority reporting no communication between referring units (Table 2).

| Neonatal care and access within health facilities
Eleven studies reported on the outcome of newborns transported into tertiary neonatal units for continued care with consistently high mortality in outborn transported neonates.39]41 In one study the mortality was 46.8%, 40 with the highest mortality being 63.5%. 29Two studies with high mortalities reported significantly increased mortalities of 44% and 51.7% in the first 48 h after delivery and transfer 29,37 (Table 3).
In relating mortality to mode of transport, one study reported an increased mortality in neonates transported by bus as compared to taxi 35 and one study reported 100% survival of babies transported by fixed-wing aircraft, compared to 70% survival if neonates transported by specially equipped ground ambulance. 28Two studies on the compliance and effectiveness of newborn referrals made by community health workers 27,42  | 21 of 25 around an organized specialized retrieval team has been associated with improved outcomes in other studies. 47,48For the SSA region, there is an urgent need to improve or implement district or regionalized neonatal referral and transport systems with a capacity to harness cost-effective measures to meet the demands of the health system.
Another critical piece of evidence was the acute inadequacy of relevant basic equipment where transport was available, 24,30,43 the absence of equipment in privately adapted ambulances, 33 or state ambulances, 12 as well as a lack of use of evidence-based costeffective methods of thermal stability.
Improving the conditions of transported sick neonates should include the prevention of hypothermia by ensuring the availability of incubators, radiant heaters, heated water-filled mattresses, and KMC. 49KMC has been recommended in a Cochrane review as an effective and safe alternative to conventional neonatal care for LBW infants, mainly in resource-limited countries. 50A study by Sontheimer in 2004 reported that infants (preterm n = 20; term n = 11) transported in a KMC position were physiologically stable and maintained a normal body temperature during ground ambulance transport. 51In the context of limited resources settings such as SSA, the unique benefits of KMC being an inexpensive method of maintaining physiologic stability during transport and also fostering parent-infant bonding and breastfeeding can be harnessed.

A
systematic literature search was conducted from inception to March 2023 of the following databases: CINAHL, EMBASE, MED-LINE, Web of Science, African Index Medicus, and Google Scholar.A combination of subject headings and keyword searches about neonates, transport or transfer, transport interventions, and all Sub-Saharan African countries was used.These were tailored to each database.The full list of search terms is available in (Appendix S1).
, intratransport, and posttransport interventions refer to all interventions instituted to improve the outcome of referred neonates.These include training in the communication of medical personnel, interfacility prereferral communication, interventions that aim to refine or upgrade already existing methods of transport, and the introduction of new methods or equipment for transport and methods to improve physiologic stability.

32 Finally, 7 18 .
An improvement in the overall neonatal outcomes in the subregion demands a critical understanding of the dynamics of the entire transfer process within the context of the resources in the subregion.This starts from the delivery of the neonate through to the decision to transfer, the transfer itself, and feedback communication to the referring facility.Evidence from this review reveals a lack of adequate human resources at all levels of this process.Reassuringly, the studies on the role of community health workers in the neonatal care and transfer process were significant.This reinforces the need to improve training and skills in neonatal stabilization and early referral by this cadre of health workers.They could also hold an answer to circumvent some of the major barriers to the transfer process in the subregion (family reluctance and patient costs related to referral) as identified by Teklu et al. years after the only systematic review in developing countries was published, 11 and halfway into the timeline for the achievement of the SDG 3 target, SSA still has a disproportionately high NMR and a dearth of well-planned studies on neonatal transport.The lack of randomized controlled studies makes the formulation of context-specific recommendations challenging.Available studies however reveal a pervasive unstructured, minimally resourced, and poorly monitored neonatal transport service with poor outcomes for transported neonates.The lack of dedicated neonatal transport teams and the heavy reliance on public transport, yet the lack of use of evidenced-based cost-effective measures of thermal stability impacts heavily on morbidity and mortality in most studies.T A B L E 3 (Continued) Study ID (year) Tette et al.

1
Study characteristics.Mode and organization of transport.
Abbreviations: HIV, human immunodeficiency virus; LBW, low birthweight; NICU, neonatal intensive care unit.T A B L E 2 Neonatal clinical outcomes.
This review summarizes the evidence to date on the transport of neonates in SSA.It demonstrates huge deficiencies in all the critical aspects of the neonatal transport service and a lack of adherence to established standards of transport.Infants delivered in the community or lower-level facilities continue to face uncertain journeys to were transported in the arms of parents or family members, on public transport with no monitoring and consequently experienced disproportionately poor outcomes at the receiving facilities.Where transportation was available, there remained huge concerns about the preparedness/training as well as the adequacy of accompanying health workers.An organized neonatal transport service centered T A B L E 3